Research letter Silent but deadly: patients with enterococcal bacteraemia should be assessed for colorectal neoplasia Eugene Athan1, Ivana Cabiltes2, Sarah Coghill3, and Steven J Bowe2,4 he epidemiology of bloodstream infections has changed The most frequent comorbid conditions in the patients for whom during the early 21st century, and our understanding of we had full records were gastrointestinal tract disease (101 of 180 Tcomplex host–pathogen relationships continues to evolve. patients, 56%), urological disease (51 patients, 28%), malignancies Enterococci have emerged as major community and health care (68 patients, 38%; including 16 cases of gastrointestinal malig- pathogens; the association of colorectal neoplasia with entero- nancy), and cardiovascular disease (122 patients, 68%). Infective coccal infections has recently been reported, particularly with endocarditis was present in 27 of 180 patients (15%), one of whom community- acquired Enterococcus faecalis bacteraemia of un- also had known colorectal cancer. In- hospital and one- year mor- known source.1,2 tality rates were 13% (24 of 180) and 40% (68 of 169 patients) respec- tively. Multivariable analysis indicated that underlying urological In contrast, the association of Streptococcus gallolyticus (previously: S. malignancy (adjusted odds ratio [aOR], 3.57; 95% confidence inter- bovis) bacteraemia with infective endocarditis and colorectal neopla- val [CI], 1.10–11.6; P = 0.035) and colorectal cancer (aOR, 4.47, 95% sia has been recognised for many years;1,3–6 25–80% of patients with CI, 1.36–14.7; P = 0.014) predicted one- year mortality. S. gallolyticus bacteraemia have concomitant colorectal tumours that can arise years after the initial presentation of infection.1,3–6 Our findings are supported by two recent studies that high- lighted the need for investigating possible colonic lesions in pa- To investigate the association of enterococcal infection with col- tients with E. faecalis bacteraemia and infective endocarditis, even orectal cancer in the Barwon region of southwestern Victoria in the absence of gastrointestinal tract symptoms. The first found (population, 300 000), we characterised the epidemiology, clin- that 6 of 28 patients with enterococcal infective endocarditis (21%) ical features, outcomes and predictors of mortality for all 376 had a new colorectal neoplasm,1 while in the second study col- patients diagnosed with enterococcal bacteraemia during 2010– orectal cancer was detected in more than half the patients with 2017. Our study was approved by the Barwon Health Research E. faecalis endocarditis with an unknown source of infection.2 Ethics Committee (reference, 17/7). In our patients, underlying urologic and colorectal cancer were The overall incidence of enterococcal bacteraemia was 19.9 cases independently associated with significantly higher one- year per 100 000 person- years; 68.4% of patients were men, and the mortality. median age was 71 years (range 27–90 years). Of 180 patients for Our study is the first in Australia to identify the importance of whom we had detailed medical records, 12 (median age, 74.5 evaluating patients with E. faecalis bacteraemia for underlying years; range, 53- 90 years), had been referred for colonoscopy solely colorectal neoplasia. Routine colonoscopy should be considered because E. faecalis bacteraemia (seven cases) or infective endocar- for patients with either S. gallolyticus or E. faecalis bacteraemia or ditis (five cases) had been diagnosed. Colonoscopy identified pre- infective endocarditis with an unclear source of infection. viously undiagnosed colorectal neoplasias in nine patients (three of five patients with infective endocarditis, six of seven with bac- Competing interests: No relevant disclosures. teraemia), including two instances of adenocarcinoma and nine Received 21 May 2018, accepted 4 July 2018. ■ of adenoma (two with high grade dysplasia, five with moderate grade dysplasia, and two with low grade dysplasia). © 2018 AMPCo Pty Ltd 1 Correidoira J, García-País MJ, Coira A, et al. Differences from a cohort of 154 patients. Rev Esp Cardiol (Engl 5 Leport C, Bure A, Leport J, Vilde JL. Incidence of co- between endocarditis caused by Streptococcus bovis Ed) 2017; 70: 451–458. lonic lesions in Streptococcus bovis and enterococ- and Enterococcus spp. and their association with col- 3 Murray HW, Roberts RB: Streptococcus bovis bac- cal endocarditis. Lancet 1987; 1: 748. orectal cancer. Eur J Clin Microbiol Infect Dis 2015; 34: teremia and underlying gastrointestinal disease. 6 Corredoira J, Alonso MP, Coira A, et al. Characteristics 1657–1665. Arch Intern Med 1978; 138: 1097–1099. of Streptococcus bovis endocarditis and its differences 2 Pericàs JM, Corredoira J, Moreno A, et al. Relationship 4 Reynolds JG, Silva E, McCormack WM. Association with Streptococcus viridans endocarditis. Eur J Clin between Enterococcus faecalis infective endocar- of Streptococcus bovis bacteremia with bowel dis- Microbiol Infect Dis 2008; 27: 285–291. ■ ditis and colorectal neoplasm: preliminary results ease. J Clin Microbiol 1983; 17: 696–697. 4 February 2019 4 February ▪ MJA 210 (2) 86 1Barwon Health, Geelong, VIC. 2Deakin University, Melbourne. 3University Hospital Geelong, Geelong, VIC. 4Swinburne University of Technology, Melbourne, VIC. eugene@barwonhealth. org.au▪doi: 10.5694/mja2.12027▪Published online 09/11/2018 .